PureEarth Technologies Fax/Mail Order Form

Print this form out, complete it, and fax or mail it to us!

Fax Order Number: (770) 514-0175
Mailing Address: 
PureEarth Technologies, Inc.
352 Friendship Court SW
Marietta, GA 30064-1557

Personal checks are accepted by mail.

Name_____________________________________________________________________

Address__________________________________________________________________

City__________________________________________State______Zip_____________

Phone #_____________________________FAX #________________________________

E-Mail______________________________

Credit Card Type (check one): Visa_____   MasterCard_____   Discover_____

Credit Card Number_______________________________________________________

Expiration Date (mm/yy)__________________

Signature________________________________________________________________

Part #             Description                        Quan.      Unit
                                                      Ordered    Price    

_______   ________________________________________     _____     _________

_______   ________________________________________     ______    _________

_______   ________________________________________     ______    _________

_______   ________________________________________     ______    _________

_______   ________________________________________     ______    _________

                                                      Subtotal   _________

                           Georgia Residents, Add 5% Sales Tax   _________

Shipping: Orders $50 or more are FREE. Less than $50, add $6.95  _________   
                                                    
                                                   Order Total   _________
           

Your order will ship via UPS (U.S. Mail to HI and AK), usually the next
business day after receipt. If your e-mail address is provided, we will 
e-mail a shipping confirmation with a UPS tracking number.


Questions? E-Mail: sales@pure-earth.com or call (800) 669-1376

Thanks for your order!